Orange County NC Website
DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 <br />ORANGE COUNTY — DEPARTMENT USE ONLY <br />Department <br />Party/Vendor Name: Triangle Urology Associates, P.A. Party /Vendor Contact Person: Pat Grinstead Contact Phone: <br />919 - 313 -3662 Party/Vendor Address: 205 Frasier Street City Durham State: NC Zip: 27707 Department: Health <br />Amount: $3,400 Purpose: Provide vasectomy services to OCHD referred males. Budget Code(s): 10414020-630000 - <br />71400 Vendor # 63847 (N /A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check <br />one) New ❑ Renewal ® Amendment ❑ Effective Date 7 -1 -18 Approved by Board Yes❑ No❑ Agenda <br />Date: <br />This agreement is approved as to to e2*fWntand content: <br />Sft,Wa <br />Department Director's Signature v a�ta Date: 8/22/2018 <br />Information Technologies <br />(Applicable only to hardware /software purchases or related services) This agreement has been reviewed and is <br />approved as to information technology content and specifications: <br />Office of the Chief Information <br />Risk Management <br />Date: <br />This agreement is approved for sufficienc iosm# aaaystandards, specifications, and requirements: <br />� <br />r gtS A. rbl b Office of the Risk Management Officer er9176888498... Date: 8/23/2018 <br />Financial Services <br />This instrument has been pre - audited i 1wquired by the Local Government Budget and Fiscal Control Act: <br />0././. 8/23/2018 <br />Office of the Chief Financial Officerec,4os Date: <br />Legal Services <br />This agreement is approved as t c9of'�SY'l qEd su- fiiciency: <br />Ql�Ui1- kavi , i wb 8/23/2018 <br />Office of the County Attorne 079GdfK,FCOFdFR Date: <br />Clerk to the Board <br />Received for record retention: <br />All Docusign contracts must be copied to Sherri Ingersoll upon completion: sin erg sollgoran eg countync.gov <br />The following signature block is for hard copies only and is not required for Docusign contracts: <br />Office of the Clerk to the Board Date: <br />Revised 10/17 (Mgr appry 5k 6/18) 4 <br />